Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease occurs when the contents of the stomach repeatedly rise into the oesophagus, causing unpleasant symptoms or damage. It can cause heartburn, regurgitation and night-time discomfort, although not everyone experiences the same symptoms.

What is gastro-oesophageal reflux disease?

Gastro-oesophageal reflux is the backflow of stomach contents into the oesophagus. This can occasionally occur in healthy people, particularly after a large meal, without necessarily indicating a medical condition.

Gastro-oesophageal reflux disease, known by the acronym GORD, is diagnosed when episodes are frequent or severe enough to cause significant symptoms, affect quality of life or cause damage to the oesophagus.

The contents that rise may be acidic, slightly acidic or contain other stomach contents. Consequently, the severity of symptoms depends not only on the amount of acid, but also on the frequency of reflux, the sensitivity of the oesophagus and its ability to clear the refluxed contents.

GORD does not present in the same way in everyone either. Some people show visible inflammation on gastroscopy, whilst others have symptoms and abnormal exposure to reflux without any apparent lesions. There are also cases with similar symptoms in which tests do not reveal pathological reflux.

Causes and associated factors

Between the oesophagus and the stomach there is a muscular area that forms part of the anti-reflux barrier. When this relaxes inappropriately or becomes less effective, gastric contents can rise more easily.

This mechanism also involves oesophageal movement, saliva production, gastric emptying and the anatomy of the junction between the oesophagus and the stomach. Therefore, GERD is usually the result of a combination of several factors rather than a single abnormality.

A hiatal hernia can contribute to reflux. It occurs when part of the stomach pushes up through the diaphragm into the chest cavity and alters the functioning of the anti-reflux barrier. Its presence, however, does not in itself determine whether GERD is present.

Being overweight, particularly around the abdomen, increases pressure on the stomach and is associated with a higher likelihood of reflux. Pregnancy can also temporarily contribute to it. Smoking and certain medicines can worsen symptoms in some people, whilst foods tend to act as individual triggers rather than a universal cause of the condition.

Symptoms

The most characteristic symptom is heartburn, a burning sensation that usually begins in the upper abdomen or behind the breastbone and may rise up towards the neck.

Regurgitation is also common, experienced as the return of liquid or food into the chest, throat or mouth. It may leave a sour or bitter taste and worsen after meals, when bending over or lying down.

Symptoms may occur intermittently or persistently. In some people, they are most pronounced at night and affect sleep; in others, they are mainly linked to certain foods or body positions.

Some people experience chest pain. When this pain is severe, occurs during exertion or is accompanied by shortness of breath, sweating or general malaise, it is important to investigate other possible causes, particularly those of cardiovascular origin.

Symptoms outside the oesophagus

Chronic cough, hoarseness, throat clearing, a persistent sensation of having something in the throat or certain respiratory symptoms may occur alongside reflux.

These symptoms, however, have numerous possible causes, and their link to GERD is usually less direct than that of heartburn or regurgitation. When they are predominant, it may also be necessary to investigate respiratory, allergic, ENT or functional causes before determining their origin.

A response to a medicine that reduces acid production can provide clinical information, but on its own it does not confirm that these symptoms are caused by reflux.

Symptoms requiring medical assessment

Difficulty swallowing, a sensation that food is getting stuck, pain when swallowing, unintentional weight loss, anaemia or gastrointestinal bleeding require medical assessment.

Persistent vomiting, unexplained loss of appetite and symptoms that have appeared recently and are progressively worsening should also be investigated. These symptoms may be related to significant inflammation, a narrowing of the oesophagus, a disturbance in its movement or other conditions requiring further investigation.

Severe or sudden-onset chest pain must be assessed as a priority, as certain cardiovascular problems can cause similar symptoms.

Diagnosis

In people with typical heartburn and regurgitation and no warning signs, the initial diagnosis may be based on the characteristics of the symptoms and, in certain cases, on the response to a correctly indicated trial treatment.

Where there is uncertainty about the cause of the symptoms, warning signs are present, the symptoms persist or the response to treatment is inadequate, it may be necessary to carry out tests to check for damage to the oesophagus or abnormal exposure to reflux.

Gastroscopy

Gastroscopy, also known as upper gastrointestinal endoscopy or oesophagogastroduodenoscopy, allows direct examination of the oesophagus, stomach and duodenum.

During the examination, oesophagitis, strictures, ulcers, Barrett’s oesophagus or other abnormalities that may explain the symptoms can be identified. Small tissue samples, known as biopsies, may also be taken when it is necessary to investigate other conditions, such as eosinophilic oesophagitis.

Biopsies are not routinely used to confirm uncomplicated GERD.

Ambulatory reflux monitoring

Many people with GERD do not show any visible lesions on endoscopy. When it is necessary to determine more precisely whether stomach contents are rising into the oesophagus in abnormal amounts, ambulatory reflux monitoring may be carried out.

This test can be carried out using a capsule that records the oesophagus’s exposure to acid over one or more days, or using a thin catheter that combines pH measurement with impedance monitoring. The latter also allows the detection of episodes of low-acid or non-acid reflux.

The test is particularly useful when the gastroscopy is normal but the diagnosis remains uncertain, when symptoms persist despite treatment, or prior to certain anti-reflux procedures. Depending on the specific issue to be addressed, it may be carried out after temporarily discontinuing medication or whilst continuing treatment.

Oesophageal manometry

Oesophageal manometry assesses the strength and coordination of the oesophagus’s contractions. Its primary aim is not to confirm GERD, but to evaluate how oesophageal motility functions and to detect disorders that may cause similar symptoms.

It also allows the junction between the oesophagus and the stomach to be precisely located prior to certain reflux monitoring tests and is usually part of the preliminary assessment when an anti-reflux procedure is being considered.

Treatment

Treatment for GERD aims to control symptoms, heal any lesions where present, and reduce the likelihood of relapses or complications. The approach depends on the frequency of symptoms, the presence of oesophagitis, the prevalence of regurgitation, previous response to treatment, and the individual’s specific circumstances.

Not all patients need continuous medication, nor do they all require the same treatment strategy. When symptoms persist, it is important to review their cause and the current treatment approach before stepping up the treatment.

Diet and lifestyle

Recommendations should be tailored to each individual’s symptoms. There is no universal list of foods to avoid for GERD, so blanket restrictions are often of little benefit if there is no clear link between a specific food and the symptoms.

It may be helpful to avoid very large meals and to leave two or three hours between dinner and bedtime, especially where night-time reflux is present. In people who are overweight or obese, weight loss can make a significant contribution to improving symptoms.

When symptoms are most severe at night, raising the head of the bed may reduce the frequency of episodes whilst lying down. Coffee, chocolate, fatty foods, alcohol, citrus fruits, tomatoes, mint or spicy foods may act as triggers in some people, but it is not necessary to cut them out unless there is a consistent link to the symptoms.

Giving up smoking brings general health benefits and may also help to improve reflux in certain patients.

Medicines

Proton pump inhibitors (PPIs) are the most effective medicines for treating reflux oesophagitis and common typical symptoms. These include omeprazole, pantoprazole and esomeprazole, as well as other medicines in the same class.

They tend to work best when taken before a meal. For many people, treatment begins with a daily regimen for several weeks, after which the response is assessed to decide how to proceed.

When treatment is effective, the aim is to find a regimen that maintains adequate control with the lowest possible dose. Some people may use these medicines intermittently or as and when needed, whilst others — particularly if they have experienced severe oesophagitis or other complications — may require long-term treatment.

PPIs have a favourable safety profile when used for the appropriate indication. The advisability of continuing them should be assessed based on their benefits and each individual’s clinical circumstances.

Alginates and antacids can provide rapid relief during occasional episodes. H2 receptor antagonists also reduce acid production and may be useful for certain mild forms of the condition or night-time discomfort, although their effect is generally less potent than that of PPIs.

When a medication has been used for a prolonged period, it is advisable to review the indication with the doctor before changing or discontinuing it.

Persistent symptoms during treatment

When symptoms persist despite treatment, the first step is to check whether the medicine is being used correctly, whether the dosage regimen is appropriate and, in particular, whether the symptoms are actually related to reflux.

Persistent symptoms may be due to insufficiently controlled reflux, but may also result from oesophageal hypersensitivity, functional heartburn, motility disorders, eosinophilic oesophagitis or other digestive or non-digestive causes.

The term ‘refractory GERD’ is primarily reserved for situations in which reflux has been confirmed and symptoms persist despite optimised treatment. In such cases, further testing may be necessary before increasing the medication or considering an intervention.

Surgery and interventional treatments

Anti-reflux surgery may be an option for selected individuals with confirmed reflux, particularly where there are persistent symptoms, significant regurgitation, specific anatomical abnormalities or a reasoned preference for an interventional approach.

The best-known surgical technique is fundoplication, which uses the upper part of the stomach to reinforce the junction between the oesophagus and the stomach. It can be performed as a complete or partial procedure, depending on the anatomical and functional characteristics of each patient.

There are also other options, such as magnetic oesophageal sphincter augmentation and certain endoscopic techniques. Their indication depends on factors such as the anatomy of the gastro-oesophageal junction, the presence and size of a hiatal hernia, oesophageal function and the experience of the team performing the procedure.

Before considering surgery, it is particularly important to establish that the symptoms are related to reflux and to properly assess oesophageal function.

Progression and possible complications

GORD usually follows a chronic or intermittent course. Some people only need treatment during certain periods, whilst others experience relapses when they stop treatment and require more ongoing management.

Where there is persistent inflammation, complications such as oesophagitis, ulcers or narrowing of the oesophagus may occur, making it difficult for food to pass through.

A proportion of patients may develop Barrett’s oesophagus, a change in the tissue lining the lower part of the oesophagus, which requires specific assessment and monitoring due to its association with an increased risk of oesophageal adenocarcinoma.

Symptom management alone does not provide sufficient information to determine whether there are lesions in the oesophagus. Similarly, the presence of GERD does not mean that everyone requires regular gastroscopies. The need for follow-up is determined based on symptoms, risk factors and the findings from investigations.

Specialists involved

The care pathway for a person with gastro-oesophageal reflux disease may vary depending on their symptoms, the progression of their condition and the tests that need to be carried out. Cases with typical symptoms and no cause for concern may initially be managed clinically, whilst persistent, atypical or more complex cases require a more specialised assessment.

At the Publio Cordón Memorial Hospital, the Digestive System Department is the centre of excellence for investigating GERD in cases of diagnostic uncertainty, persistent symptoms, difficulty swallowing, the need to adjust treatment or where specific tests are indicated. The department comprises various units dedicated to the diagnosis and treatment of digestive disorders.

When it is necessary to examine the oesophagus and stomach directly via gastroscopy, take biopsies or assess reflux-related lesions, the Digestive Endoscopy Unit may be involved. The unit carries out diagnostic and therapeutic endoscopic procedures and deals with both general digestive disorders and more complex conditions.

In certain patients, functional tests of the oesophagus may also be required, such as pH and impedance monitoring or oesophageal manometry. These investigations help to clarify the diagnosis when gastroscopy does not explain the symptoms, to investigate persistent discomfort, and to properly prepare patients for whom anti-reflux surgery is being considered.

If, following completion of the investigation, it is considered that surgical intervention may be beneficial, the assessment may continue within the Department of General and Gastrointestinal Surgery. The decision to operate is made after taking into account the symptoms, the anatomy, the tests demonstrating reflux and the function of the oesophagus; therefore, surgery forms part of the care pathway for selected patients and not for all cases of GERD.

When symptoms outside the digestive system predominate, the care pathway may be extended. Hoarseness or a persistent change in the voice may require assessment by the Department of Otorhinolaryngology or, where indicated, by the Department of Rhinology, Laryngology and Voice, to examine the larynx directly and rule out other causes of the symptoms.

Similarly, a persistent cough should not automatically be attributed to reflux. Where this is the predominant symptom, the involvement of the Respiratory Medicine department may be necessary and, depending on the characteristics of the case, that of the Chronic Cough and Respiratory Infections Unit, whose aim is to identify the possible causes of a persistent cough and guide its treatment.

Thus, the team involved does not necessarily have to remain the same throughout the entire process. One person may only require assessment and treatment by the Gastroenterology team; another may require a gastroscopy and functional tests; and, in specific situations, it may be necessary to involve surgeons, ENT specialists, Pulmonology specialists or other specialists. The aim is for each professional to be involved when their expertise helps to clarify the diagnosis or select the most appropriate treatment.

Living with gastro-oesophageal reflux disease

Understanding which situations trigger symptoms allows you to adjust your habits without imposing unnecessary restrictions. Some people need to change the time they have dinner, the size of their meals or the position they sleep in; others manage their symptoms effectively with medication and require very few changes to their daily routine.

It is not necessary to permanently eliminate all foods traditionally associated with reflux. Restrictions make more sense when there is a clear and recurring link to symptoms, and it is worth reviewing them if they unnecessarily reduce dietary variety.

When night-time reflux, pain or regurgitation affect sleep, work or eating habits, it is advisable to review the diagnosis and treatment rather than simply accepting these discomforts as the new normal.

The management of GERD may change over time. An appropriate strategy combines an understanding of personal triggers, the correct use of medication where indicated, and a clinical reassessment should new symptoms arise or the usual pattern of the condition change.

Medical information for general guidance

The purpose of this content is to help readers understand gastro-oesophageal reflux disease, its mechanisms, the symptoms it can cause, and the various ways in which it can be diagnosed and treated. It also aims to help explain why some people can manage the condition with simple measures, whilst others require a gastroscopy, functional tests or a specialist assessment.

At the Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each individual through their care journey. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible manner, helping patients and their families to better understand each stage and participate with greater confidence in decisions regarding their health. This commitment to knowledge and public outreach is also part of our dedication to research and the advancement of medicine.

The information provided in this factsheet is general in nature and cannot be used to make a diagnosis or select an individual treatment. A medical assessment must take into account a person’s symptoms, medical history, physical examination, response to previous treatments and, where necessary, diagnostic tests.

In the event of severe symptoms, those that appear suddenly, or those consistent with a possible medical emergency, a proper medical assessment is required.